Addressing Suicide: Is Treatment More Important Than Therapist?

Brian Thompson, Ph.D.

Often when people are looking for a therapist, they ask about who is "good" or an "expert." There are those who seek out a particular type of therapy; for example, some people contact me because I'm trained in Acceptance and Commitment Therapy. For the most part, however, people are less concerned with the specific type of treatment they receive.

A study by Dr. Marsha Linehan at the University of Washington suggests that type of treatment may make a big difference for people who have Borderline Personality Disorder (BPD), a chronic condition associated with difficulty effectively managing one's emotions, multiple suicide attempts, physical self-harm (e.g., cutting on one's self), and impulsive, often destructive actions. Dr. Linehan developed Dialectical Behavior Therapy (DBT) specifically to address suicidal impulses in people with BPD, and it has become the gold standard of treatment for people with BPD.

In a two-year study of treatment for women with BPD, DBT therapists were compared to non-DBT community experts. Mental health community leaders in the Seattle, WA area nominated for the study community therapists recognized as experts. As DBT is considered a cognitive behavioral therapy (CBT), the researchers selected community expert therapists who did not practice CBT. The community experts met at an extremely well respected and prestigious institution for supervision. They were allowed to practice therapy however they saw fit. The community experts identified mainly as "eclectic" or "psychodynamic." Once therapists were chosen for the study, the researchers randomly selected women with BPD who had volunteered for the study to see either a DBT therapist or a community expert. The results were examined after one year of treatment.

One really interesting difference between the DBT therapists and the community experts is that the experts had more clinical experience than the DBT therapists. Additionally, half of the DBT therapists had no experience with DBT and were specifically trained for the study after being nominated by colleagues. If we believed that experience was more important than the type of therapy delivered, this would give the community experts the advantage. Not only were they experienced, but colleagues had also nominated them as being exceptional therapists.

The results were sobering for those more experienced therapists out there...

Despite being less experienced therapists, the women who saw DBT therapists had about half as many suicide attempts and fewer emergency department visits and hospitalizations for feeling suicidal. Moreover, the community expert therapists had extremely high dropout rates. Nearly 60% of the clients seeing community experts left treatment early, whereas only 25% seeing DBT therapists did. Lastly, DBT therapists were more effective than community experts in addressing substance use. This is important, as dependence on drugs and alcohol is associated with a greater risk of committing suicide for people with BPD.

Prior to this study, DBT was already recognized as an extremely important treatment for highly suicidal people with BPD. This research reaffirms that for highly suicidal people with BPD, choosing the proper treatment could be crucial.